Caesarean scar pregnancy: a review of management options

Paradoxical air embolism in patients undergoing hysteroscopic surgery for cesarean scar pregnancy: A case report and review of the literatures

Cesarean scar pregnancy cases who undergo hysteroscopic suction aspiration could be at higher risk of air emboli due to dilated, low-resistant, high-velocity blood vessels.

Early first-trimester transvaginal ultrasound screening for cesarean scar pregnancy in patients with previous cesarean delivery: analysis of the evidence

Obstetric hemorrhage is a leading cause of maternal morbidity and mortality. An important etiology of obstetric hemorrhage is placenta accreta spectrum. In the last 2 decades, there has been increased clinical experience of the devastating effect of undiagnosed, as well as late diagnosed, cases of cesarean scar pregnancy. There is a growing body of evidence suggesting that cesarean scar pregnancy is an early precursor of second- and third-trimester placenta accreta spectrum. As such, cesarean scar pregnancy should be diagnosed in the early first trimester. This early diagnosis could be achieved by introducing regimented sonographic screening in pregnancies of patients with previous cesarean delivery. This opinion article evaluates the scientific and clinical basis of whether cesarean scar pregnancy, with special focus on its early first-trimester discovery, complies with the accepted requirements of a screening test. Each of the 10 classical screening criteria of Wilson and Jungner were systematically applied to evaluate if the criteria were met by cesarean scar pregnancy, to analyze if it is possible and realistic to carry out screening in a population-wide fashion.

Surgical treatment and reproductive outcomes in caesarean scar pregnancy at a single center

BACKGROUND

To investigate factors associated with different reproductive outcomes in patients with Caesarean scar pregnancies (CSPs).

METHODS

Between May 2017 and July 2022, 549 patients underwent ultrasound-guided uterine aspiration and laparoscopic scar repair at the Gynaecology Department of Hubei Maternal and Child Health Hospital. Ultrasound-guided uterine aspiration was performed in patients with type I and II CSPs, and laparoscopic scar repair was performed in patients with type III CSP. The reproductive outcomes of 100 patients with fertility needs were followed up and compared between the groups.

RESULTS

Of 100 patients, 43% had live births (43/100), 19% had abortions (19/100), 38% had secondary infertility (38/100), 15% had recurrent CSPs (RCSPs) (15/100). The reproductive outcomes of patients with CSPs after surgical treatment were not correlated with age, body mass index, time of gestation, yields, abortions, Caesarean sections, length of hospital stay, weeks of menopause during treatment, maximum diameter of the gestational sac, thickness of the remaining muscle layer of the uterine scar, type of CSP, surgical method, uterine artery embolisation during treatment, major bleeding, or presence of uterine adhesions after surgery. Abortion after treatment was the only risk factor affecting RCSPs (odds ratio 11.25, 95% confidence interval, 3.302-38.325; P < 0.01) and it had a certain predictive value for RCSP occurrence (area under the curve, 0.741).

CONCLUSIONS

The recurrence probability of CSPs was low, and women with childbearing intentions after CSPs should be encouraged to become pregnant again. Abortion after CSP is a risk factor for RCSP. No significant difference in reproductive outcomes was observed between the patients who underwent ultrasound-guided uterine aspiration and those who underwent laparoscopic scar repair for CSP.

The use of pressure balloons in the treatment of first trimester cesarean scar pregnancy

Cesarean scar pregnancy (CSP) is among the most severe complications of cesarean delivery. CSP refers to the abnormal implantation of the gestational sac in the area of the prior cesarean delivery (CD), potentially leading to severe hemorrhage, uterine rupture, or development of placenta accreta spectrum disorders (PAS). The management of women with CSP has not been standardized yet. In women who opted for termination, discussion about the treatments should consider maternal symptoms, gestational age at intervention, and the future reproductive risk. A multitude of treatments, either medical or surgical, for CSP has been reported in the published literature. The present review aims to provide up-to-date information on a recently introduced minimally invasive treatments for CSP, including the single and double balloon catheter. The methodology of using the single or double catheter is described in a step-by-step fashion illustrated by pictures as well as video recordings. Both catheters have their deserved place to be used as a primary method for terminating scar pregnancies as well as using them as adjuncts to other treatments. They were successfully used by multiple individual practitioners and institutions due to their simplicity and low complication rates. The rare, but possible post-procedure complications such as recurrent CSP and enhanced myometrial vascularity are also mentioned.

Predictability of Hematological Parameters in the Diagnosis of Cesarean Scar Pregnancy

Introduction  Cesarean scar pregnancy (CSP) is an increasing clinical condition that causes serious maternal morbidity and mortality. This study aimed to evaluate if inflammation markers measured by hemogram can aid in the diagnosis of CSP. Materials and Methods  A total of 86 patients were included in the study. The cases were divided as CSP ( n : 42) and normal pregnancy (NP) ( n : 44). At the time of admission, peripheral blood neutrophils, lymphocytes, monocytes, thrombocytes, systemic inflammatory index (SII) (neutrophil × platelet/lymphocyte), neutrophil-lymphocyte ratio, monocyte-lymphocyte ratio, and platelet-lymphocyte ratio were all measured. CSP and NP diagnoses were made by transabdominal or vaginal ultrasonography. Results  In the CSP group, mean age ( p  < 0.001), gravida ( p  < 0.001), parity ( p  < 0.001), number of surviving children ( p  < 0.001), number of abortions ( p  < 0.001), cesarean number ( p  < .001), dilatation and curettage count ( p  = 0.013), monocyte (M) value ( p  = 0.039) and monocyte/lymphocyte value (MLR) ( p  = 0.035) were significantly higher than the control group. The optimal M value cut-off value was found to be > 0.40, the sensitivity value was 78.57, and the specificity value was 50.00. AUC = 0.632 (SE = 0.061) for the MLR value. The optimal MLR cut-off value was found to be > 0.232, the sensitivity value was 61.90, and the specificity value was 63.64. Conclusion  Hemogram parameters, which are simple, inexpensive, and easily accessible, M and MLR are significantly higher in the diagnosis of CSP and can be used as an auxiliary parameter for ultrasonography.

Clinical efficacy and safety of high-intensity focused ultrasound (HIFU) ablation in treatment of cesarean scar pregnancy (CSP) I and II

Objective

To investigate the safety and feasibility of high intensity focused ultrasound (HIFU) ablation followed by ultrasound-guided dilation and curettage (USg-D&C) for two types patients with cesarean scar pregnancy (CSP-I and CSP-II).

Materials and methods

This study was a retrospective analysis of 101 CSP-I patients and 52 CSP-II patients who received HIFU ablation followed by USg-D&C from Jun 2014 to Oct 2020. The diameter of gestational sac/mass, thickness of the intervening myometrium, intraoperative blood loss, operation time, length of hospital stays, adverse effects and β-HCG level in the two groups were compared.

Results

All patients successfully received HIFU ablation under conscious sedation. The median total treatment time of HIFU ablation and median USg-D&C time in the CSP-I group were statistically longer than those in the CSP-II group (P < 0.05). The average intraoperative median blood loss was 39 ml in the CSP-I group and 65 ml in the CSP-II group (P < 0.05). The duration of hospitalization was 7.07 ± 1.83 days in the CSP-I group and 7.18 ± 1.72 days in the CSP-II group (P > 0.05). The average time needed for β-HCG return to normal levels was 26.08 ± 5.02. and 28.15 ± 4.99 days for CSP-I and CSP-II, respectively (P > 0.05). The percentage of adverse effects and complications was not significantly different between the two groups (P > 0.05).

Conclusions

HIFU ablation followed by USg-D&C was safe and effective in treating the CSP-I patients and CSP-II patients, which may be a potential noninvasive therapeutic option for patients with CSP.

Diagnosis and Management of Ectopic Pregnancy: A Comparative Review of Major National Guidelines

Importance

Ectopic pregnancies (EPs) represent a severe early pregnancy complication that is associated with increased risks of maternal morbidity and mortality. Over the years, there has been a significant reduction in the mortality from this complication by improving the diagnostic tools and the treatment options.

Objective

The aim of this study was to review and compare the recommendations from published guidelines on this potentially fatal condition.

Evidence Acquisition

A descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists, the Royal College of Physicians of Ireland, the Society of Obstetricians and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists, and the National Institute for Health and Care Excellence on EP was carried out.

Results

All the guidelines point out the crucial role of sonography in the prompt diagnosis of EP and describe similar sonographic findings. There is a consensus on the indications and contraindications to the use of methotrexate, the post-treatment surveillance, and the criteria of expectant management. The indications for a surgical approach are not well established, although the Royal College of Obstetricians and Gynaecologists, the Royal College of Physicians of Ireland, the American College of Obstetricians and Gynecologists, and the National Institute for Health and Care Excellence agree that a laparoscopy is preferred to laparotomy for hemodynamically stable patients. The latter is considered a better option only in emergency conditions. However, there is controversy in the recommended methotrexate protocols and the evaluation of β-human chorionic gonadotrophin and progesterone levels.

Conclusion

It is of paramount importance to build consistent international protocols, so as to help clinicians all over the world diagnose EPs in the most timely and accurate way and subsequently treat them effectively as a nonurgent medical condition, with the intention to lower the mortality and morbidity rate.

A Comparison of Transvaginal Removal and Repair of Uterine Defect for Type II Cesarean Scar Pregnancy and Uterine Artery Embolization Combined With Curettage

Background: There is no consensus on a standardized therapy for type II cesarean scar pregnancy (CSP II). The objective of the present study was to evaluate the efficacy and safety and compare costs associated with transvaginal removal and repair (TRR) of uterine defect for CSP II to those of uterine artery embolization (UAE) and curettage.

Methods: We conducted a retrospective study that included 87 patients diagnosed with CSP II and treated by performing UAE in combination with curettage and hysteroscopy (n = 53), or TRR (n = 34). Clinical data and outcomes were analyzed.

Results: UAE and TRR groups exhibited similar success rates. The TRR group had significantly lower complication rates (30.19 vs. 8.82%, P < 0.05) and lower total costs (13,765.89 ± 2,029.12 vs. 9,063.82 ± 954.67, P < 0.05) than the UAE group. The anterior myometrium of the lower uterine segment was relatively thicker after performing TRR, and no patient suffered from recurrent CSP II. The proportion of patients in the TRR group who had full-term delivery without uterine rupture was 88.24% (30/34), while four patients failed to pregnancy.

Conclusion: TRR is a safe and effective treatment method for patients with CSP II and presents a highly cost-effective outcome, especially for patients with future fertility desire.

A comparison between laparoscopy and hysteroscopy approach in treatment of cesarean scar pregnancy

The aim of the study was to compare the efficacy of laparoscopy and hysteroscopy for the treatment of cesarean scar pregnancy (CSP) and analyze the clinical factors associated with successful selection for hysteroscopic or laparoscopic treatment of CSP.We retrospectively studied 112 cases of CSP that were treated by laparoscopy and/or hysteroscopy in our hospital from December 2014 to December 2017. In total, 72 of these patients underwent ultrasound-guided curettage and hysteroscopic resection without uterine scar defect repair. Fourty of these patients underwent laparoscopic resection and repair of the uterine scar defect. We analyzed the different clinical variables between the 2 groups and identified the clinical factors which could predict the need for the laparoscopic repair of uterine scar defect. Results showed that laparoscopy and hysteroscopy were safe ways to treat CSP, and no patient underwent hysterectomy. The β-hCG level in both of the 2 groups decreased to normal 4 to 8 weeks after surgery. There were significant differences between the hysteroscopy group and laparoscopy uterine scar repair group in terms of days of amenorrhea, gestational sac diameter, myometrial thickness, operation time, intraoperative blood loss, and hospitalization duration (P < .05). Logistic regression analysis showed that the days of amenorrhea, gestational sac diameter and myometrial thickness were independent risk factors for CSP treated by minimally invasive surgery, which were also shown by ROC curve analysis to be predictors of the need for the repair of the uterine scar defect, with optimal cutoffs of 52.50 days, 3.25 cm, and 2.05 mm, respectively; and the areas under their corresponding ROC were 0.721, 0.851, and 0.927, respectively.We conclude that laparoscopy and hysteroscopy are safe and efficient minimally invasive procedures for the treatment of CSP. The days of amenorrhea, gestational sac diameter and myometrial thickness may be key factors associated with successful selection for hysteroscopic or laparoscopic treatment of CSP.

Combination of medical and surgical management in successful treatment of caesarean scar pregnancy: a case report series

Background

There is no clear consensus on the management of caesarean scar pregnancy (CSP), a complex and life-threatening condition. The objective of this study was to present a novel approach to management of CSP that combines medical therapy of multidose methotrexate and mifepristone with active surgical management by uterine curettage and consecutive local haemostasis.

Case presentation

We report on a prospective case series of six women with first trimester pregnancy, in whom the diagnosis of CSP was confirmed by 2D and color Doppler transvaginal ultrasound and serial hormone chorionic gonadotropin (hCG) testing. Women were between 23 and 36 years old and had at least one previous delivery by caesarean. At admission, gestational age ranged between 6 to 14 weeks, and serum hCG levels between 397 and 23,000 mUI/ml. Upon decision of pregnancy termination, medical management was undertaken in all cases and 1 mg/kg systemic Methotrexate was administered between 1 and 5 daily doses. Mifepristone was part of the treatment in cases with live pregnancy. Surgical management was employed for the cases were an embryo was seen by ultrasound, being prompted by inadequate response to Methotrexate and/or signs of miscarriage with vaginal bleeding. Curettage combined with local isthmic balloon or vaginal pack tamponade prevented further complications. High treatment rates with preservation of fertility was achieved in all patients except one who underwent hysterectomy for invasive placentation. Ultrasound and hCG levels surveillance ensured that the resolution of pregnancy was achieved.

Conclusion

Women with history of delivery by caesarean section should be carefully monitored in future pregnancies for prompt diagnosis of CSP. Early diagnosis of CSP allows selection of successful conservative therapy. Through this case series we contribute with our experience to the body of knowledge about the management of this serious complication of early pregnancy.

Interventions for non-tubal ectopic pregnancy

BACKGROUND

Non-tubal ectopic pregnancy is the implantation of an embryo at a site lying outside the uterine cavity or fallopian tubes. Sites include a caesarean scar, the cornua uteri, the ovary, the cervix, and the abdomen. There has been an increasing trend in the occurrence of these rare conditions, especially caesarean scar pregnancy (CSP).

OBJECTIVES

To evaluate the clinical effectiveness and safety of surgery, medical treatment, and expectant management of non-tubal ectopic pregnancy in terms of fertility outcomes and complications.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, the World Health Organization (WHO) search portal and nine other databases to 12 December 2019. We handsearched reference lists of articles retrieved and contacted experts in the field to obtain additional data.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) published in all languages that examined the effects and safety of surgery, medical treatment, and expectant management of non-tubal ectopic pregnancy.

DATA COLLECTION AND ANALYSIS

We used Cochrane standard methodological procedures. Primary outcomes were treatment success and complications.

MAIN RESULTS

We included five RCTs with 303 women, all reporting Caesarean scar pregnancy. Two compared uterine arterial embolization (UAE) or uterine arterial chemoembolization (UACE) plus methotrexate (MTX) versus systemic MTX and subsequent dilation and suction curettage; one compared UACE plus MTX versus ultrasonography-guided local MTX injection; and two compared suction curettage under hysteroscopy versus suction curettage under ultrasonography after UAE/UACE. The quality of evidence ranged from moderate to very low. The main limitations were imprecision (small sample sizes and very wide confidence intervals (CI) for most analyses), multiple comparisons with a small number of trials, and insufficient data available to assess heterogeneity. UAE/UACE versus systemic MTX prior to suction curettage Two studies reported this comparison. One compared UAE with systemic MTX and one compared UACE plus MTX versus systemic MTX, in both cases followed by a suction curettage. We are uncertain whether UAE/UACE improved success rates after initial treatment (UAE: risk ratio (RR) 1.00, 95% CI 0.90 to 1.12; 1 RCT, 72 women; low-quality evidence; UACE: RR 0.87, 95% CI 0.54 to 1.38; 1 RCT, 28 women; low-quality evidence). We are uncertain whether UAE/UACE reduced rates of complications (UAE: RR 0.47, 95% CI 0.13 to 1.75; 1 RCT, 72 women; low-quality evidence; UACE: RR 0.62, 95% CI 0.26 to 1.48; 1 RCT, 28 women; low-quality evidence). We are uncertain whether UAE/UACE reduced adverse effects (UAE: RR 1.58, 95% CI 0.41 to 6.11; 1 RCT, 72 women; low-quality evidence; UACE: RR 1.16, 95% CI 0.32 to 4.24; 1 RCT, 28 women; low-quality evidence), and it was not obvious that the types of events had similar values to participants (e.g. fever versus vomiting). Blood loss was lower in UAE/UACE groups than systemic MTX groups (UAE: mean difference (MD) -378.70 mL, 95% CI -401.43 to -355.97; 1 RCT, 72 women; moderate-quality evidence; UACE: MD -879.00 mL, 95% CI -1135.23 to -622.77; 1 RCT, 28 women; moderate-quality evidence). Data were not available on time to normalize β-human chorionic gonadotropin (β-hCG). UACE plus MTX versus ultrasonography-guided local MTX injection We are uncertain whether UACE improved success rates after initial treatment (RR 0.95, 95% CI 0.56 to 1.60; 1 RCT, 45 women; very low-quality evidence). Adverse effects: the study reported the same number of failed treatments in each arm (RR 0.88, 95% CI 0.40 to 1.92; 1 RCT, 45 women). We are uncertain whether UACE shortened the time to normalize β-hCG (MD 1.50 days, 95% CI -3.16 to 6.16; 1 RCT, 45 women; very low-quality evidence). Data were not available for complications. Suction curettage under hysteroscopy versus under ultrasonography after UAE/UACE. Two studies reported this comparison. One compared suction curettage under hysteroscopy versus under ultrasonography after UAE, and one compared these interventions after UACE. We are uncertain whether suction curettage under hysteroscopy improved success rates after initial treatment (UAE: RR 0.91, 95% CI 0.81 to 1.03; 1 RCT, 66 women; very low-quality evidence; UACE: RR 1.02, 95% CI 0.96 to 1.09; 1 RCT, 92 women; low-quality evidence). We are uncertain whether suction curettage under hysteroscopy reduced rates of complications (UAE: RR 4.00, 95% CI 0.47 to 33.91; 1 RCT, 66 women; very low-quality evidence; UACE: RR 0.18, 95% CI 0.01 to 3.72; 1 RCT, 92 women; low-quality evidence). We are uncertain whether suction curettage under hysteroscopy reduced adverse effects (UAE: RR 3.09, 95% CI 0.12 to 78.70; 1 RCT, 66 women; very low-quality evidence; UACE: not estimable; 1 RCT, 92 women; very low-quality evidence). We are uncertain whether suction curettage under hysteroscopy shortened the time to normalize β-hCG (UAE: MD 4.03 days, 95% CI -1.79 to 9.85; 1 RCT, 66 women; very low-quality evidence; UACE: MD 0.84 days, 95% CI -1.90 to 3.58; 1 RCT, 92 women; low-quality evidence). Non-tubal ectopic pregnancy other than CSP No studies reported on non-tubal ectopic pregnancies in locations other than on a caesarean scar.

AUTHORS' CONCLUSIONS

For Caesarean scar pregnancies (CSP) it is uncertain whether there is a difference in success rates, complications, or adverse events between UAE/UACE and administration of systemic MTX before suction curettage (low-quality evidence). Blood loss was lower if suction curettage is conducted after UAE/UACE than after administration of systemic MTX (moderate-quality evidence). It is uncertain whether there is a difference in treatment success rates, complications, adverse effects or time to normalize β-hCG between suction curettage under hysteroscopy and under ultrasonography (very low-quality evidence). There are no studies of non-tubal ectopic pregnancy other than CSP and RCTs for these types of pregnancy are unlikely.

Successful technique of manual vacuum aspiration for treatment of type 2 cesarean scar pregnancies: evaluation of 40 cases

OBJECTIVE

To demonstrate the effectiveness and safety of the defined manual vacuum aspiration (MVA) technique for treatment of type 2 cesarean scar pregnancies (CSPs).

METHODS

We treated 40 patients with CSP by MVA at the Early Pregnancy Clinic of our hospital between 1 January 2012 and 31 December 2014. The files of patients were reviewed and evaluated retrospectively. Eligibility criteria were hemodynamic stability and at least 2 mm myometrial thickness at the anterior part of the CSP. The key-point of successful MVA procedure is to keep away from entering the cesarean scar cavity directly; instead, CSP is displaced from the implantation site by applying vacuum, only while the cannula is passing near.

RESULTS

During the study period, the ratio of CSP to total pregnancies was 1/1000. The ratio of CSP to cesarean delivery (CD) was 1/372. In that time period, CSPs were constituted 4.41% of all ectopic pregnancies. Total of 40 patients were treated with dilatation and MVA. Complications such as excessive hemorrhage, persistence of CSP, and any need of extra intervention were not observed. The beta-hCG values of 21 patients (52.5%) decreased below 10 mIU/mL after the first 15 days, and the rest decreased below 10 mIU/mL after 3 weeks following MVA.

CONCLUSIONS

This MVA technique for treatment of CSP is easily applicable and effective method with high success and low complication rates. For appropriately selected patients, we think that this method can be considered as the first- line treatment.

Scoring system for the prediction of the successful treatment modality in women with cesarean scar pregnancy

OBJECTIVE

To establish a risk scoring system to predict the successful treatment of cesarean scar pregnancy.

METHODS

A prospective observational study was conducted between June 2016 and March 2018 in a tertiary care center. Patients received evacuation followed by uterine artery embolization and laparoscopic local resection/hysterectomy successively as salvage measures if necessary. Optimal scaling regression determined the extent of each potential prognostic factor predicted.

RESULTS

Out of 228 women, 144 cases required evacuation before recovery, 73 women required uterine artery embolization, and 11 women eventually required laparoscopic surgery. Six variables were included in the predictive model: number of cesarean deliveries; maximal diameter of gestational sac; remnant myometrial thickness; grading of Doppler signals; presence of fetal heartbeat; and location of gestational sac. A 10-point scoring system was established by weighting their prediction of the method of successful treatment. In the risk score rank of 1-4, only 4 (2.8%) out of 142 women needed uterine artery embolization as a salvage treatment, while in the risk score rank of 8-10, 41 (80.4%) cases needed uterine artery embolization; laparoscopic operations were performed by physicians for the other 10 (19.6%) cases.

CONCLUSION

The successful treatment of cesarean scar pregnancy was accurately predicted by a 10-point scoring system.

CHINESE CLINICAL TRIALS REGISTRY

ChiCTR-OOC-16008467.

Retrospective study of patients with cesarean scar pregnancies treated by uterine artery chemoembolization and curettage

OBJECTIVE

To evaluate the efficacy and long-term prognosis of uterine artery chemoembolization (UACE) combined with curettage for treatment of cesarean scar pregnancy (CSP).

METHODS

Data were retrospectively reviewed from women with CSPs treated by UACE with curettage at Women's Hospital of Zhejiang University, Hangzhou, a tertiary obstetrics and gynecologic center in China, between December 2006 and December 2016. Information on clinical characteristics and treatment outcomes was obtained from medical records and follow-up interviews.

RESULTS

There were 383 patients included; 379 (99.0%) women were successfully treated. Risk factors associated with intraoperative bleeding were size of gestational mass (P=0.001), presence of fetal heart beat (P=0.002), and type of CSP (P=0.002). Among 301 women with complete medical records over a mean ± SD follow-up of 49.8 ± 30.2 months, 164 (54.5%) women resumed normal menstruation and only 22 (7.3%) experienced a reduction in menstrual volume of more than one-half. Among 89 women attempting to conceive, the conception rate was 69% (61/89), the positive pregnancy rate was 80% (49/61), and 35 live neonates were delivered.

CONCLUSION

UACE combined with curettage was found to be an effective fertility-sparing treatment for CSP. Further, the approach did not seem to harm future reproductive ability.

The value of 3-dimensional color Doppler in predicting intraoperative hemorrhage for cesarean scar pregnancy

The aim of this study is to evaluate the efficacy of 3-dimensional (3D) ultrasonography and 3D color power Doppler ultrasound in the management of cesarean scar pregnancy (CSP).A case-control study enrolled 190 CSP patients who underwent uterine artery embolization (UAE) in combination with dilatation and curettage (D&C). The maximum diameter of gestational sac or CSP mass, uterine scar thickness, and resistance index (RI) were measured by 2D ultrasound. The lesion volume, vascular index (VI), flow index (FI), blood vessels, and blood flow index (VFI) were assessed by 3D ultrasound. The changes of these parameters before and after UAE were analyzed. Then, the patients were divided into bleeding group and control group according to the intraoperative hemorrhage during D&C to access and compare the significance of 2D and 3D parameters in intraoperative hemorrhage.The mean VI and the mean VFI were significantly reduced after embolization (P < .01). In the bleeding group, the lesion volume and diameter of gestational sac or CSP mass were significantly larger, VI and VFI were significantly higher, the uterine scar thickness was thinner, and RI was lower (P < .05). The best indicator for prediction of massive intraoperative bleeding was the VI with an area under the curve of 0.870, the best cut-off value of VI was 7.500, and the sensitivity and specificity were 88.2% and 82.4%, respectively. In comparing the receiver operating characteristic curves among 2D and 3D ultrasound parameters, the diagnostic efficacy of lesion volume was significantly higher than maximum diameter (P < .001). The diagnostic efficacy of VI was significantly higher than maximum diameter (P = .020) and RI (P = .011).UAE reduces the number of vessels and the blood flow perfusion obviously; however, it does not reduce lesion size or increases myometrial thickness. Three-dimensional ultrasonography and power Doppler, especially VI, lesion volume may be helpful in predicting excessive bleeding during D&C after UAE.

Management of Caesarean scar pregnancy with or without methotrexate before curettage: human chorionic gonadotropin trends and patient outcomes

Background

To evaluate the effects of systemic methotrexate in cesarean scar pregnancy (CSP) patients treated with ultrasound-guided suction curettage.

Methods

A retrospective review of all women presenting with CSP treated with ultrasound-guided suction curettage at Tongji Hospital, Wuhan, China, between January 1, 2013 and December 31, 2015, was conducted. Patients were grouped into those not treated with methotrexate before curettage (group 1), treated with methotrexate by intramuscular injection (group 2) and treated with methotrexate by intravenous injection (group 3). The clinical characteristics and outcomes were analyzed.

Results

Among 107 patients, 47 patients were not treated with methotrexate before curettage, 46 patients had methotrexate administered by intramuscular injection and 14 patients had methotrexate injected intravenously. There were no significant differences among the groups in basic and clinical characteristics, such as age, gravity, parity, positive fetal heart beat and gestational age at diagnosis. Patients presented similar initial human chorionic gonadotropin (hCG) levels in all groups. After treatment with methotrexate or curettage, the percentage changes and varied ranges of the hCG levels were also similar in all groups. There were no significant differences in intraoperative blood loss and retained products of conception among the three groups. However group 1 had significantly shorter hospital stays than the two groups that were treated with methotrexate (p<0.001).

Conclusion

By grouping CSP patients who shared similar age, gravity, parity, fetal heart beat positive and gestational age at diagnosis, we found that the presence or absence of methotrexate treatment before curettage resulted in comparable outcomes and hCG levels, although patients who were not treated with methotrexate had significantly shorter stays in the hospital.

Normal vaginal delivery at term after expectant management of heterotopic caesarean scar pregnancy: a case report

Background

Heterotopic pregnancy with a combination of a caesarean scar pregnancy and an intrauterine pregnancy is rare and has potentially life-threatening complications.

Case presentation

We describe the case of a 27-year-old white woman who had experienced an emergency caesarean delivery at 39 weeks for fetal distress with no postpartum complications. This is a report of the successful expectant management of a heterotopic scar pregnancy. The gestational sac implanted into the scar area was non-viable. The woman was treated expectantly and had a normal vaginal delivery at 37 weeks of gestation.

Conclusion

Expectant management under close monitoring can be appropriate in small non-viable heterotopic caesarean scar pregnancies.

Clinical and ultrasound parameters in prediction of excessive hemorrhage during management of cesarean scar pregnancy

PRECIS

During the management of cesarean scar pregnancy, gestational mass size >6 cm, uterine scar thickness <0.2 cm, peak systolic velocity >70 cm/s, and resistance index <0.35 are independent risk factors for excessive hemorrhage.

OBJECTIVE

The objective of this study was to investigate risk factors associated with excessive hemorrhage during the management of cesarean scar pregnancy (CSP).

PATIENTS AND METHODS

A retrospective case-control study was conducted, including 40 patients who experienced excessive bleeding and 80 controls without severe hemorrhage.

RESULTS

Six parameters (two clinical and four ultrasound parameters) potentially related to excessive hemorrhage were analyzed. Single-variable statistical analyses showed that the case group had higher gestational age (74.1±23.6 days), higher pretreatment serum β-human chorionic gonadotropin (HCG) level (46,201±32,294 mIU/mL), larger gestational mass size (6.5±2.2 cm), thinner uterine scar thickness (0.17±0.12 cm), and richer peritrophoblastic perfusion (peak systolic velocity [PSV] 72.8±33.7 cm/s, resistance index [RI] 0.35±0.12), showing statistical significance compared with the control group. Further multivariable logistic regression analysis of the association between each of the risk factors and hemorrhage confirmed that increased gestational mass size and PSV were risk factors for hemorrhage (odds ratio [OR] 3.624, 95% confidence interval [CI] [1.179-11.138] and OR 1.062, 95% CI [1.007-1.121]) and increased uterine scar thickness and RI were protective factors against hemorrhage (OR 0.181, 95% CI [0.034-0.957] and OR 0.851, 95% CI [0.729-0.994]); however, there was no statistical significance between the two clinical parameters.

CONCLUSION

Gestational mass size >6 cm, uterine scar thickness <0.2 cm, PSV >70 cm/s, and RI <0.35 are independent risk factors for excessive hemorrhage during the management of CSP.

Management of a Viable Cesarean Scar Pregnancy: A Case Report

The incidence of cesarean scar pregnancy (CSP), which was extremely rare till recent times, has been rising steadily. We have more of such cases being published in medical literature now. A 38-year-old woman with a past history of previous three cesarean sections presented with five weeks pregnancy and complaints of bleeding per vaginum associated with mild lower abdominal discomfort. The diagnosis of CSP with a live fetus within the gestational sac was made on a transvaginal ultrasound examination and later confirmed with a magnetic resonance imaging (MRI). The management involved injecting potassium chloride into the gestational sac and a combination of local and systemic methotrexate administration. The patient was followed-up by monitoring the beta human chorionic gonadotropin level until it reached non pregnant level and followed-up with scan and MRI until complete resolution of the pregnancy sac. Due to the rarity of this condition, there are no specific guidelines available for its management.

The Treatment of Cesarean Scar Pregnancy with Uterine Artery Embolization and Curettage as Compared to Transvaginal Hysterotomy

OBJECTIVES

To investigate the outcome and menstrual status in patients after treatment of cesarean scar pregnancy (CSP) by transvaginal hysterotomy or uterine artery embolization combined with uterine curettage.

STUDY DESIGN

A retrospective cohort study. An analysis of CSP patients was performed using records from Shanghai First Maternity & Infant Hospital affiliated with Tongji University for the period between July 16, 2014 and January 22, 2016. Twenty-seven patients were treated with transvaginal hysterotomy and in this group, 49 patients received uterine curettage after UAE. The clinical information on these patients and clinical outcomes especially the status of menstruation were reviewed.

RESULTS

There was only one complication in transvaginal hysterotomy group, while 3 cases of villus residue occurred in UAE group. Nineteen patients (70.4%) in transvaginal hysterotomy group self-assessed their menstrual volumes, which had no remarkable changes; 6 patients (22.2%) felt that their menstrual volumes had decreased. Thirty-five patients in UAE group (71.4%) reported that their menstrual volumes decreased (P<0.05). The range of pictorial blood loss score was 55-82 in transvaginal hysterotomy group and 9-74 in UAE group, and the mean pictorial blood loss score was decreased from 68.4 to 65.8 in transvaginal hysterotomy group (a 3.2±4.4% reduction) and from 66.4 to 38.8 in UAE group (a 41.7±26.4% reduction) (P<0.05).

CONCLUSIONS

Transvaginal hysterotomy appears to be more advantageous than UAE combined with uterine curettage. The menstrual interval and duration changed significantly in UAE group.

First-trimester diagnosis and management of Cesarean scar pregnancies after in vitro fertilization-embryo transfer: a retrospective clinical analysis of 12 cases

BACKGROUND

Although Caesarean scar pregnancy (CSP) is rare, it can cause life-threatening complications. The increasing rate of Cesarean delivery plus rapid development of in vitro fertilization-embryo transfer (IVF-ET) may increase the occurrence of CSP as well as the ratio of heterotopic CSP (HCSP)/CSP. Therefore, early diagnosis and management of CSP are necessary to avoid serious complications. And the purpose of this article is to evaluate the importance and feasibility of the first-trimester diagnosis and management of CSP after IVF-ET.

METHODS

All the 12 cases were secondary infertility patients who had a history of Cesarean section and underwent IVF-ET in our reproductive center. All cases with CSP were diagnosed using transvaginal color Doppler sonography (TVS). Medical, surgical and expectant managements were implemented, and the management results were traced.

RESULTS

Patients with CSP (n = 12) were diagnosed from January 2011 to April 2015, 6 (50 %) of which were HCSP. The prevalence of CSP was 1:1688 pregnancies. The gestational age ranged from 5 + 3 to 7 + 4 weeks in all CSP, and from 5 + 6 to 7 + 4 weeks in HCSP at diagnosis. Five patients received successful surgical treatment. The success rate of medical and expectant management was 50 % (1/2) and 100 % (5/5), respectively. One patient with failed medical management needed an emergency laparotomy to evacuate CSP. The uterus was preserved in all 12 patients.

CONCLUSIONS

The Caesarean section and IVF-ET may increase the ratio of HCSP/CSP. TVS is a noninvasive and effective tool for use in diagnosing CSP. CSP should be carefully excluded in patients who have had a history of Caesarean section. Early diagnosis of CSP in the first trimester may contribute towards the preservation of uterus as well as intrauterine pregnancy (IUP) in HCSP.

Novel Medical Therapy of Cesarean Scar Pregnancy With a Viable Embryo Combining Multidose Methotrexate and Mifepristone: A Case Report

An ectopic pregnancy is defined as cesarean scar pregnancy (CSP) when the products of conception are implanted within the myometrium in the area of a cesarean section scar. CSP can be a life-threatening condition and to date there is no clear consensus for CSP management. A medical approach joining high treatment rates with fertility preservation could be a safer and less invasive method of therapy.We present a case of CSP with a viable embryo that was successfully treated with a novel medical therapy combining multidose methotrexate (MTX) and mifepristone.No further additional invasive procedure was required since pregnancy products were dissolved and no major complications were experienced.Multidose MTX and mifepristone can be considered a safe and effective treatment for CSP.

Cesarean scar pregnancy treated by curettage and aspiration guided by laparoscopy

Pregnancy in a cesarean scar is the rarest form of an ectopic pregnancy. The treatment for cesarean scar pregnancy mainly includes systemic methotrexate and uterine artery embolization. Here, we reported a case of cesarean scar pregnancy treated by curettage and aspiration guided by laparoscopy. The treatment plan included two phases. Three days after a combination of methotrexate and mifepristone was administered, the gestational sac was removed under laparoscopy, which enabled a successful treatment for the unruptured ectopic pregnancy in a previous cesarean scar and made it possible to preserve the reproductive capability of the patient.

Outcome of cesarean scar pregnancies diagnosed sonographically in the first trimester

OBJECTIVES

The purpose of this study was to determine the outcome of cesarean scar pregnancies diagnosed during the first trimester.

METHODS

We retrospectively identified all cesarean scar implantation pregnancies diagnosed by sonography before 14 weeks' gestation between 2000 and 2012 at our institution. We reviewed the patients' sonograms and medical records and recorded sonographic findings and pregnancy outcomes.

RESULTS

Thirty-four cases met study entry criteria. Ten patients presented with no embryonic cardiac activity, of whom 7 underwent interventions, and 3 were expectantly managed. One of the former 7 and none of the latter 3 required hysterectomy for bleeding. Among the 24 patients with embryonic cardiac activity, 8 were managed expectantly: 5 (62.5%) ultimately delivered a live-born neonate, 3 (60.0%) of whom required hysterectomy due to placenta accreta; and 3 had fetal demise. Sixteen of the 24 underwent interventions, 2 opting for gravid hysterectomy (10 and 11 weeks' gestation, respectively) and 14 treated by a minimally invasive method: intrasac potassium chloride injection (3 cases); intrasac potassium chloride injection plus intramuscular methotrexate (4 cases); sonographically guided dilation and curettage (6 cases); and laparascopic resection (1 case). None of the latter 14 subsequently required hysterectomy.

CONCLUSIONS

If a woman has a first-trimester diagnosis of a cesarean scar implantation pregnancy and embryonic cardiac activity is present, expectant management offers the possibility of delivering a live-born neonate (62.5% in our study) but carries a substantial likelihood of hysterectomy at delivery due to placenta accreta (37.5% in our study), whereas minimally invasive therapy that interrupts the pregnancy largely eliminates the need for hysterectomy.

Operative Therapy for Heterotopic Scar Pregnancy and Successful Birth of the Intrauterine Foetus - Case Report and Review of the Literature

A heterotopic pregnancy in the vicinity of a previous Caesarean section scar (HSP) occurs frequently after fertility treatment. In spite of the low incidence to date, the increasing numbers of Caesarean sections as well as IVF treatment will probably lead to a higher prevalence in the future. Up to now the literature contains only isolated case reports on therapeutic options. These range from conservative management through selective termination of the HSP by injections of methotrexate or potassium chloride into the amniotic sac to invasive methods such as resectoscopic removal or laparoscopy. In the case presented here we describe the successful excision of the HSP by laparotomy with a subsequent uncomplicated Caesarean section and delivery of a healthy baby at the 37 + 0 week of pregnancy.

Comparative efficacy and safety of local and systemic methotrexate injection in cesarean scar pregnancy

Objective

To investigate the efficacy of methotrexate (MTX) injection in treatment of cesarean scar pregnancy (CSP).

Method

A randomized controlled study was performed in 104 CSP patients receiving either local or systemic MTX injection at the Peking Union Medical College Hospital from the year 2008 to 2013.

Results

Complete cure was defined as regression of ultrasonographic findings and normalization of serum β-hCG within 60 days. It was regarded as delayed cure if additional dilation and curettage (D&C) was needed. The overall cure rate (complete cure plus delayed cure) was 69.2% versus 67.3% for local injection versus systemic administration (P>0.05). The median time for serum β-hCG remission and uterine mass disappearance after systemic administration (42 [21–69] days and 40 [20–67] days) were significantly lower than those receiving local injection (56 [24–92] days and 53 [23–88] days), with P=0.029 and 0.046, respectively. The mean pretreatment serum β-hCG (human chorionic gonadotropin) level and lesion size in cured group (21,941±18,351 mIU/mL and 2.9±1.3 cm, respectively) were significantly lower than those in the failed group (37,047±30,864 mIU/mL and 3.6±1.3) with P=0.038 and 0.044, respectively.

Conclusion

MTX injection is effective in CSP treatment. Systemic administration shows similar overall cure rate compared to local injection, but requires shorter time for serum β-hCG remission and uterine mass disappearance.

Low-lying-implantation ectopic pregnancy: a cluster of cesarean scar, cervico-isthmus, and cervical ectopic pregnancies in the first trimester

OBJECTIVE

To describe the treatment outcomes of aberrant ectopic implantations in the lower segment of the uterus in a cohort population and to evaluate whether or not low-lying-implantation ectopic pregnancy (LLIEP), a new term, is appropriate to include in the traditional diagnoses of cervical pregnancy (CP), cesarean scar pregnancy (CSP), and other unusual aberrant implantations in the lower segment of the uterus in the first trimester, in terms of clinical characteristics, treatment, and prognosis.

MATERIALS AND METHODS

Forty-two women with ectopic pregnancies of <12 weeks' gestational age from July 2003 to December 2008 were prospectively studied. Each patient underwent an ultrasound evaluation by an experienced consultation team and was grouped into the CP, CSP, or cervico-isthmic pregnancy (CIP) group. Patients underwent either suction dilatation and curettage (D and C) alone, or laparoscopic uterine artery blockage followed by suction D and C, to remove the aberrant trophoblasts without other adjuvant treatments. Clinical characteristics and biochemical factors, including obstetric history, patient age, body mass index (BMI), gestational age, serum hematocrit and β-hCG level, operation method, operation time, and intraoperative blood loss were evaluated.

RESULTS

There were no significant differences in patient age (mean = 34.1 ± 6.4 years), previous number of cesarean deliveries (mean = 1.5 ± 0.8), gestational age (mean = 6.9 ± 1.2 weeks), serum β-hCG (mean = 35,384.3 ± 41,726.9 mIU/mL), operation time (mean = 60.3 ± 46.6 minutes), and surgical blood loss (mean = 124.7 ± 191.5 mL) among the three patient groups. The uterus was successfully preserved in all patients after treatment.

CONCLUSION

The prognosis of surgical management for ectopic implantations in the lower segment of the uterus is good. The new term LLIEP seems appropriate to cover all forms of aberrant ectopic implantations in the lower segment of the uterus in the first trimester, in terms of treatment efficacy. The use of LLIEP for preoperative ultrasound diagnosis would enable the clinician to diagnose unusual cases more easily, without the need to change the current treatment policy.

Combined laparoscopy and hysteroscopy vs. uterine curettage in the uterine artery embolization-based management of cesarean scar pregnancy: a retrospective cohort study

Background

The number of cesarean scar pregnancy (CSP) has significantly increased in the recent decade. Although uterine artery embolization (UAE) has been adopted to minimize the blood loss during uterine curettage removing of CSP, massive bleeding and uterine rupture can still be frequently encountered. The aim of this study was to compare the efficacy and safety of a novel combined laparoscopy and hysteroscopy technique with the traditional curettage in removing the conceptus and repairing the incision defect following the UAE management of CSP.

Methods

The CSP patients (n = 58) diagnosed between March 1, 2005 and March 1, 2010 were enrolled in three medical centers in Shanghai, China. All of these patients have undergone intra-arterial methotrexate, UAE and one of the following treatments: combined laparoscopy and hysteroscopy (study group, n = 25) and uterine curettage (control group, n = 33). Their medical records and 2-year outcomes were reviewed. The CSP removal rate, amount of blood loss during the treatment, incision repair rate (note: the post-curettage healing process of the incision defect was seen as a form of natural incision repairing, i.e., the self-repair mode), hospital stay, β-hCG regression time and postoperative sequelae were compared between two groups.

Results

The CSP removal rate in the study group (100%) was significantly higher than that (79%) in the control group (p = 0.024). The average blood loss was 78.0 mL in the study group, which was much less than the 258.5 mL (p = 0.004) in the control group. A satisfactory incision repair rate (96%) was achieved in the study group, while it was 25% (p < 0.001) in the control group. Moreover, the study group had significantly shorter hospital stays (p = 0.043) and β-hCG regression times (p = 0.033), lower rates of postoperative abdominal pain (p = 0.035) and menstruation abnormalities (p = 0.043).

Conclusions

Combined laparoscopy and hysteroscopy is much safer and more effective than uterine curettage as a supplementary measure to remove the conceptus and repair the cesarean incision following the UAE management of CSP.